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Determining the severity of depression combines a play-it-by-the-book (DSM IV) approach to asking about each possible depressive symptom with an intuitive awareness of what could happen (call it clinical “thinking dirty”) as the sex addict in treatment relates to mounting consequences. These steps are suggested:
1. Take no shortcuts in the intake process. Get a broad anthropological/cultural view of the person while conducting a careful search for symptoms and signs of depression and/or suicidal ideation and plans. The cultural context and support system have a telling influence on suicidal potential.
2. Withhold too early conclusions about character pathology. “Hip-shooting” labeling (e.g. borderline, narcissistic, antisocial) only closes off possibilities in the clinician’s mind and prevents the therapist from seeing the patient in all his/her potential for resilient recovery or calamities such as suicide.
3. Request psychological testing to back up interview data and clinical observations. Something may surface that was not considered earlier (e.g. schizotypal thinking or a low-grade thought disorder.
4. Search out nooks and crannies in relation to suicidaland homicidal thoughts. For example, if a person denies active suicidal thoughts, he/she may still wish that a semi-truck would meet them head on. Likewise, even though a patient is a mother of children and says she would never kill herself because her children need her, has she recently bought life insurance or given away belongings?
5. Review any past history of suicidal ideation or attempts. What are the similarities and differences (e.g. strength or lack of strength of support network) to the present situation? Has the person ever faced anything as humiliating as the exposure of sex addict behavior?
6. Consider, “How deep is this person’s shame?” Will the person consider suicide to be the only “viable” way out of a lifelong shame-existence bind?
7. Inquire about how the person has taken out anger in the past. Toward self? Toward others? He/she is likely to follow the same pattern again.
8. Determine the dynamic significance of the type of sexual acting out practiced by the patient (e.g. the exhibitionist who could never get his mother’s attention). Has that meaning been processed with the patient and the power taken out of the pattern, or does shame still envelop the patient and fuel suicidal/homicidal thoughts?
9. Measure whether the patient’s medication for severe depression is at a therapeutic level. Smoldering along with depression that is only partially treated can heighten the patient’s hopelessness and could lead to suicide (e.g. Is this as good as it gets?).
10. Assess medication compliance. What has been the response of the depression to medication? Does the patient understand the importance of taking medication as prescribed, and for as long as prescribed? Are any side effects intolerable to the patient (e.g. decreased sex drive, anorgasmia, or impotence)?
11. Examine any progress made in treatment in processing anger, shame, and other overwhelming emotions. Have the circumstances of the person’s life changed for the better? For the worse? Remember, if nothing changes, nothing changes.
12. Gauge employment and economic prospects. Has sex-addict behavior led to consequences at work? Will there be further repercussions and consequences?
13. Ask the patient what he or she sees for the future. Hope or hopelessness?
14. Practice appropriate boundary setting with the patient as he/she relates to co-workers and people outside the circle of recovering sex addicts. To whom will the person claim sex addiction, and with whom will anonymity and strict boundaries be maintained? Role play some of these scenarios. Would the person rather die than face so-and-so?
15. Concretize after care plans. Who will see the patient for out-patient treatment? Is that therapist knowledgeable about sex addiction treatment and recovery? Will the therapist refer the patient if suicidality becomes prominent again? Is extended care needed? How many and what type of Twelve Step meetings will the person attend? Will the person get a sponsor and work Steps, or will he/she remain a “movie critic” at meetings as in the past? Will the person “put your whole self in” to recovery, like the song says?
16. Bring to light the person’s growth or lack thereof of a concept of a Higher Power. Does the person think his/her preciousness is a reality? Would a Higher Power really care? Is there still a false Higher Power operating (e.g. money, power, self, another addiction, or a partner)?
In summary . . .
The sex addict is really hurting. It is the clinician’s task to assess where the pain could lead while providing a safe, healing, holding environment.
Depression present at the start of treatment often deepens as shame crashes down upon the addict whose acting out pattern is revealed. Suicidal ideation at the “between trapeze” moment is a likely probability. The educated clinician’s index of suspicion will help to anticipate the presence and depth of depression, and the existence of self-destructive thoughts or plans. Caring and professional assessment and treatment will allow the sex addict to survive the shock of discovery and move toward the daily rewards of a healthy and spiritual recovery.
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